Nokea
A student is reviewing a patients chart before giving care. She notes the following diagnoses in the contents of the chart: appendicitis and acute pain. Which of the diagnoses is a medical diagnosis?
- A. neither appendicitis nor acute pain
- B. both appendicitis and acute pain
- C. appendicitis
- D. acute pain
Correct Answer: C
Rationale: Appendicitis is a medical diagnosis made by a physician, while acute pain is a nursing diagnosis based on patient symptoms.
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The nurse takes a patients vital signs and finds the pulse rate to be 120 beats/min. What would the nurse do next to interpret and analyze this pulse rate?
- A. Compare the patients pulse rate to the standard range.
- B. Notify the patients healthcare provider.
- C. Document the pulse in the appropriate chart page.
- D. Ask another nurse to verify the pulse rate.
Correct Answer: A
Rationale: Comparing the pulse rate to the standard range is the next step to determine if it is abnormal and requires further action.
In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?
- A. to collect information about subjective and objective data
- B. to correlate nursing and medical diagnostic criteria
- C. to identify etiologies of health problems
- D. to evaluate mutually developed expected outcomes
Correct Answer: C
Rationale: Identifying etiologies of health problems is a key purpose of the diagnosing step, as it helps determine the underlying causes of a patient's health issues, guiding appropriate interventions.
A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing health habits. What conclusion did the nurse reach after interpreting and analyzing the data?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: A
Rationale: Recommending reinforcement of health habits suggests no immediate problem was identified, indicating a 'no problem' conclusion.
Which of the following patient care concerns is clearly a nursing responsibility?
- A. prescribing medications
- B. monitoring health status changes
- C. ordering diagnostic examinations
- D. performing surgical procedures
Correct Answer: B
Rationale: Monitoring health status changes is a core nursing responsibility, as it involves assessing and tracking patient conditions, unlike prescribing medications or performing surgeries, which are medical responsibilities.
A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase Disturbed Self-Esteem identify?
- A. the expected outcome of the plan of care
- B. a cue to determining a health problem
- C. the major defining characteristic of a health problem
- D. the health state or problem of the patient
Correct Answer: D
Rationale: Disturbed Self-Esteem' identifies the patient's health state or problem in the nursing diagnosis.